Impact of Immediate Initiation of Antiretroviral Therapy on HIV Patient Satisfaction

Osondu Ogbuoji; Pascal Geldsetzer; Cebele Wong; Shaukat Khan; Emma Mafara; Charlotte Lejeune; Fiona Walsh; Velephi Okello; Till Bärnighausen


AIDS. 2020;34(2):267-276. 

In This Article

Abstract and Introduction


Objectives: Immediate ART (or early access to ART for all, EAAA) is becoming a national policy in many countries in sub-Saharan Africa. It is plausible that the switch from delayed to immediate ART could either increase or decrease patient satisfaction with treatment. A decrease in patient satisfaction would likely have detrimental consequences for long-term retention and adherence, in addition to the value lost because of the worsening patient experience itself. We conducted a pragmatic stepped-wedge cluster-randomized controlled trial (SW-cRCT) to determine the causal impact of immediate treatment for HIV on patient satisfaction.

Design: This seven-step SW-cRCT took place in 14 public-sector health facilities in Eswatini's Hhohho region, from September 2014 to August 2017.

Methods: During each step of the trial, we randomly selected days for data collection at each study facility. During these days, a random sample of HIV patients were selected for outcome assessment. In total, 2629 patients provided data on their overall patient satisfaction and satisfaction with the following four domains of the patient experience using a five-point Likert scale: wait time, consultation time, involvement in treatment decisions, and respectful treatment. Higher values on the Likert scale indicated lower patient satisfaction. We analyzed the data using a multilevel ordered logistic regression model with individuals at the first level and health facilities at the second (cluster) level.

Results: The proportional odds ratio (OR) comparing EAAA to control was 0.91 (95% CI 0.66–1.25) for overall patient satisfaction. For the specific domains of the patient experience, the ORs describing the impact of EAAA on satisfaction were 1.04 (95% CI 0.61–1.78) for wait time, 0.90 (95% CI 0.62–1.31) for involvement in treatment decisions, 0.86 (95% CI 0.61–1.20) for consultation time, and 1.35 (95% CI 0.93–1.96) for respectful treatment. These results were robust across a wide range of sensitivity analyses. Over time – and independent of EAAA – we observed a worsening trend for both overall patient satisfaction and satisfaction in the four domains of the patient experience we measured.

Conclusion: Our findings support the policy change from delayed to immediate ART in sub-Saharan Africa. Immediate (versus delayed) ART in public-sector health facilities in Eswatini had no effect on either overall patient satisfaction or satisfaction with four specific domains of the patient experience. At the same time, we observed a strong secular trend of decreasing patient satisfaction in both the intervention and the control arm of the trial. Further implementation research should identify approaches to ensure high patient satisfaction as ART programs grow and mature.


Following the WHO revision of the guidelines for antiretroviral therapy (ART) in 2013,[1] and subsequently in 2015/2016,[2,3] many countries began the process of transitioning towards providing immediate treatment for HIV, which has also been called Early Access to ART for All (EAAA), 'Universal Test and Treat' (UTT), and 'Treatment as Prevention' (TasP). The evidence from the HPTN052 trial[4,5] and several HIV epidemiologic studies[6–9] promise a decline in HIV incidence by adopting the EAAA strategy. These studies have demonstrated reductions in HIV incidence and suggest economic benefits of early access to testing and treatment.

Missing from the current evidence on EAAA is how it will affect HIV patients' satisfaction with care in routine treatment programs.[10] In theory, EAAA could affect patient satisfaction through many pathways. It could have a positive impact on patient satisfaction if patients value the early onset of treatment, which frees them from the psychological burden of delaying treatment while waiting for the HIV disease to get worse. Conversely, it could have a negative impact on patient satisfaction – for example, through the psychological and emotional stress patients might feel if required to commit to life-long treatment immediately after receiving a life-changing diagnosis. EAAA might also cause significant increases in patient volume, which in turn, could lead to less health worker time spent per patient, longer queues, and increased health worker stress – all of which could reduce patient satisfaction. Lastly, and maybe most importantly, EAAA might negatively affect average patient satisfaction through compositional changes to the patient population receiving ART.[11] Patients with late-stage HIV disease are more likely to experience the powerful recovery and health improvement that follows commencement of treatment compared to those with early-stage disease. Individuals in early stages of HIV disease are more likely to still feel healthy when treatment starts and the main physical change following HIV treatment in these patients may be the experience of HIV side effects. This difference in the experience of recovery could affect patient satisfaction.

Patient satisfaction is important for several reasons. For one, it has intrinsic value, because the treatment process should be responsive to patients' legitimate demands and respectful of their underlying wants.[12,13] Moreover, patient satisfaction also has instrumental value through its effect on patients' behaviors. Patients who are dissatisfied with their care are more likely to disengage from care[14,15] and fail to reengage after disengagement.[15,16] Dissatisfied patients are also more likely to refuse or delay treatment[17] and to miss medications if already on treatment.[14,18] Therefore, if EAAA reduces patient satisfaction, it could negatively impact HIV treatment programs and the course of the HIV epidemic.

The Maximizing ART for Better Health and Zero New HIV Infections (MaxART) trial, a pragmatic stepped-wedge cluster-randomized controlled trial (SW-cRCT) of EAAA in Eswatini, was designed to 'quantify the causal impact of early access to ART for all on patient satisfaction'[19] as a prespecified secondary endpoint. Viral with viral suppression and retention in care were the primary endpoints. This study, therefore, aims to determine the causal impact of EAAA on overall patient satisfaction, as well as four specific domains of the patient experience (wait time, consultation time, involvement in treatment decision-making, and respectful treatment). To our knowledge, the results below are the first rigorous causal test of the hypothesis that EAAA changes patient satisfaction.